Date of Admission: 06/28/XX

Date of Discharge: 07/07/XX

Diagnoses: 1. Status post fractured right femoral neck.

2. Chronic obstructive pulmonary disease.

3. Rheumatoid arthritis, steroid dependent.

4. Osteoporosis.

Pertinent History: The patient was admitted on the 28th of June after a fall. She did not pass out but just fell and fractured her hip. She fell off of a stool at home. She underwent surgery for this. She had a hemiarthroplasty. She tolerated the procedure well and was transferred to A Pavilion for continued physical therapy and rehabilitation.

Pertinent Laboratory: CBC initially showed a white count of 15,400, subsequently the white count is 10,900 with 78 neutrophils. H&H was stable at 12.2 and 36.9. Theophylline level was 10.3, therapeutic.

Hospital Course: The patient tolerated physical therapy well. She was able to give her own Lovenox shots. She was anxious to go home on Saturday. Orthopedics had planned for 14 more days of Lovenox, and that will be given by the patient and prescribed by Dr. Thomas's group. She will be back in about 3 weeks. She will continue with her current medications, which are Proventil 2 puffs q.i.d., Fosamax 10 mg q.a.m., Soma 350 mg q.i.d., Lovenox 30 mg q. 12 hours, folic acid 1 mg q. day, Lasix 40 mg b.i.d., Atrovent 2 puffs q. 6 hours, Synthroid 0.075 q day, potassium 20 mEq b.i.d., prednisone 20 mg a day, Theo-Dur 100 mg in the morning and 200 mg in the evening. She takes Sonata and she will continue with 5 mg q.h.S. She will continue with her laxative of choice. She will restart her Nasonex, Celebrex, Vicodin, and Vanceril when she gets home. She will stay on a regular diet. Activities per her primary care physician. She will see me back in 3 weeks.

History and Physical Examination

Admission Date: 6/28

Chief Complaint: Hip fracture.

Present Illness: The patient is a 79-year-old white female who slipped off of a stool in her apartment's kitchen while talking to her daughter. She was apparently trying to do too many things at one time, trying to clean some books or something like that and then just slipped and fell off and fractured her hip. She lives alone and had to call for help. She denies any type of passing out, no head injury, and no history of falling a lot before.

Past Medical History: The patient denies any kind of past history of chest pains, exertional chest pain. She stopped smoking some time ago but continues to be mildly short of breath and that has been stable.

She has no gastrointestinal (GI) symptoms, only occasionally some mild stress incontinence.

Medications: 1. Nasonex nasal spray

2. Soma 350 mg 1 q.i.d.

3. Potassium 10 mEq. 2 b.i.d.

4. Celebrex 200 mg q.d.

5. Synthroid 0.075 q.d.

6. Vicodin p.r.n.

7. Fosamax 10 mg q.a.m.